Life as an Expert in: Clinical Psychology

I am Dr Kari Carstairs. I am an HCPC registered clinical psychologist who has dedicated her whole working life to gaining a deep understanding of people’s thoughts, feelings and behaviour, with a particular emphasis on human distress in its many forms.

My career

I obtained my BA in Experimental Psychology from the University of Oxford in 1982.  I then worked for three years in a range of mental health positions, two of which were in in-patient settings, one of which was in a classroom for emotionally disturbed children in a therapeutic community in the USA and the third involved supporting vulnerable older adults in their own homes in the community in London.  In 1985, I returned to the USA where I had spent my early childhood to begin my clinical training.

I started graduate school thinking that psychological testing was just about pigeon-holing people – the real understanding came from the intimacy of the psychotherapeutic relationship.  During the course of the training, I had the good fortune to have a wonderful instructor, Dr Clifford DeCato, who taught the Rorschach and other psychological tests.  His enthusiasm for testing made me think again.  His insistence on a careful scrutiny of the test data, combined with his delight in what was quirky, different or unique about a person inspired me.  Thanks to him, I have had an abiding fascination in the use of psychometric techniques for the assessment of personality, especially the Rorschach, which has served me well in my role as an expert witness.  I am now the President of the British Rorschach Society and I am a Fellow of the Society for Personality Assessment.  I carry out research in psychological testing and I have had numerous publications in this area of practice, including most recently in 2018 a normative study with the Rorschach for which I was the lead author with six other psychologists.

I graduated with distinction for my Doctorate in Clinical Psychology from Widener University in the USA in 1991. My dissertation was on infant development and it formed the basis for an article that was published in the International Journal of Psycho-Analysis in 1992. I obtained my licence to practice in the state of Pennsylvania and worked briefly in the Philadelphia Child Guidance Clinic before returning to England in 1991 for personal reasons.

My first NHS post was in adult mental health in Maidstone.  It was split three ways between providing short term therapy in GP surgeries, providing long term therapy in a psychology department and provision of a psycho-diagnostic service to the in-patient psychiatric admissions ward.  After five years in that post, I moved to Oxleas NHS Trust where I worked in a specialist, tertiary Integrated Psychological Therapies Service providing individual psychodynamic psychotherapy to adults with a personality disorder.

I gradually began to do Court reports, receiving professional support and encouragement from a forensic psychologist from the USA who came to work in England on a “sabbatical”.  I am very grateful to her.  She helped me to hone my skills in testing and showed me how these skills could be applied in the Court.  I found that I loved the work, with the requirement to blend careful, well-reasoned formulations, based on sound scientific findings, with an in-depth psychological understanding of the person I am assessing and then apply this to the legal setting.  I started a part-time private practice in 1993 and gradually built this up, offering assessment and treatment services for adults.  I left the NHS in 1998 and I set up my limited company in 2006.

Now I provide Court reports in civil, criminal and family cases and I have a team of associates who assist me in this work and take cases on my behalf.  In 2004, I obtained the Cardiff University/Bond Solon Certificate of Expert Witness Accreditation.  In 2011, I obtained Diplomate status with the American Board of Assessment Psychology, with a speciality in forensic assessment.  I have assessed over 400 clients for the Courts since 1994 when I started this work and I have a particular interest in personality disorder, post-traumatic stress disorder, chronic pain and malingering and complex cases where expert evidence is contested.  I have had ten associates over the years since 2001, all of whom worked under my supervision and provided over 700 reports for the Company between them.  My first associate continues to work with me to this day.

Civil cases

In civil cases, my defendant/claimant split is approximately 30/70.  My cases are generally large complex medical negligence cases where experts from several disciplines are required.  There may be a pre-existing history of mental health issues so that I need to tease out the question of what was already in evidence from the impact of subsequent medical events or there may be a sequence of separate traumatic events such that working out causation becomes a real puzzle.

A psychological assessment has much to offer in relation to treatment planning and prognosis in chronic pain cases.

I have a particular interest in chronic pain cases. Pain and depression are the most prevalent physical and psychological symptom-based disorders, respectively, and there is a close relationship between the two conditions.  Pain is a risk factor for depression and vice versa.  Various childhood risk factors are related to depression and chronic pain later in life. Parental mental health, childhood history of sexual abuse, childhood functional limitations and family functioning are all related to co-morbid depression and chronic pain conditions.  The combination of both of these disorders is associated with worse clinical outcomes than either condition alone. A psychological assessment has much to offer in relation to treatment planning and prognosis in chronic pain cases.

Family Cases

I wonder about the quality of decision-making for these troubled families.

In family cases where the Local Authority is involved due to child protection concerns, I have been instructed to provide a psychological assessment of parents or carers to determine if there are psychological issues relevant to decision-making about the placement of the children. Instructions include cognitive assessment of learning disability, psychological assessment of mental health and personality, dynamics in the relationship between people sharing caring roles, insight into Local Authority concerns, capacity to engage with professionals, capacity to meet children’s needs, capacity for change, treatment or support needs and evidence of change.  However, sadly, due to cuts in legal aid, these types of cases are less often brought to an expert now, as compared to when I first started this work and as a result, I wonder about the quality of decision-making for these troubled families.

Criminal Cases

In large fraud cases, trials are likely to be lengthy and require attention to detailed financial transactions, with a considerable information processing demand on the participants.

I have assessed several defendants facing charges of fraud where there is a question of fitness to stand trial for the criminal Courts and I very much enjoy the challenges of these cases.  The accused is considered to be fit if he or she can plead to the indictment, understand the course of proceedings, instruct a solicitor, challenge a juror and understand the evidence.  Mental health issues can interfere with a person’s capacity to manage these demands but equally, the possibility of malingering must also be considered.  A psychologist should always consider the possibility that the defendant may not be truthful in any report for the Court, but this becomes a particularly acute issue in cases where the defendant is charged with fraud. With other types of crime, dishonesty is not necessarily an integral part of the offence, whereas fraud is by definition a crime of dishonesty.  A multi-method approach is essential and the psychologist should never rely on an interview alone.  Psychometric data complements the interview and a thorough review of documentation pertaining to the alleged offence and to the person’s medical history.  Although psychologists cannot claim to have a “litmus test” for lying, there are well-established techniques, supported by a considerable body of peer-reviewed research, for assessing the reliability of the defendant’s self report.

In large fraud cases, trials are likely to be lengthy and require attention to detailed financial transactions, with a considerable information processing demand on the participants.   The psychologist needs to integrate the results from the assessment with the specific demands that the defendant would face if the case goes to trial in order to reach an opinion about how this individual would cope in that situation and consider whether any special measures might ameliorate any potential deficits and render the person fit.

 

The Importance of Medical Records

One might question that since psychologists are not medically trained, why would they want to see the GP records?

Psychological assessment for the Courts relies on different types and sources of information. This includes background information, such as GP records, police records, and statements from the parties. It includes information gathered through clinical interview of the person being assessed and through the administration of psychological tests, along with behavioural observation. Psychometric testing provides a systematic, objective method of collecting data.  It augments information obtained in the clinical interview which is more open to interpretation. The assessment may also make use of information gathered through interviewing other people who know the individual and through obtaining historical records held by other professionals, such as therapists who have treated the individual. Lastly, the assessment may also include reference to information from published research.

One might question that since psychologists are not medically trained, why would they want to see the GP records?  Much of the information about matters such as prescriptions for common infections, blood test results and the details for vaccines is not something that a psychologist is qualified to form an opinion on.  However, these records often contain a wealth of information that informs all of my reports for the Courts, regardless of whether the case is a civil compensation claim, a criminal case or a family case, and I always ask to see them.  Sometimes, there are issues of direct relevance, such as any letters from other mental health professionals.  Sometimes, notes from the GP will raise important questions to follow up in an interview, for example, a comment when the examinee was a child about a possible learning difficulty.

Being able to write a good report is central to working as an expert witness.  However, it is not sufficient.

Courtroom experience

Being able to write a good report is central to working as an expert witness.  However, it is not sufficient.  One also has to be able to give evidence in Court.  I have given evidence many times over the years for both the defence and the prosecution in criminal cases, including at the Central Criminal Court. In care proceedings cases, I have given evidence at the Royal Courts of Justice.  To date, I have not yet been required to give evidence in a personal injury compensation claim as all of the cases I have been involved in have settled without proceeding to this step.  When I have given evidence, I have found the Judges to be excellent and I have never been personally attacked in Court, although I have been asked some searching questions.  This only serves to keep me on my toes!  I welcome the opportunity to explain my thinking and although I may have a moment of anxiety before taking the witness stand, I consider that this is appropriate because of the weighty responsibility of the task.  When under cross-examination, I draw on my undergraduate experience at Oxford where I was required to defend my essays in individual tutorials with tutors who sought to question my thinking rigorously and thoroughly.  It was excellent preparation for expert witness work!

Treatment services

In addition to doing about one assessment per month these days for the Courts, I also provide individual psychotherapy to adults.  I completed a four-year psychoanalytic training with the Site for Contemporary Psychoanalysis in 2017, registering as a psychotherapist with the UKCP.  Most of my current therapy patients come between two and four times a week over a period of many years for long term, intensive psychoanalytic treatment but I also sometimes offer short term and brief interventions depending on the patient’s needs. I regularly supervise other psychologists, both for assessments and for therapy, and I take part in peer supervision as well in order to get feedback and keep myself open to different perspectives.

In conclusion

Over the course of my career, since seeing my first patient in graduate school, I have worked with hundreds of people with all sorts of psychological problems, in diverse settings ranging from a college counselling centre through to in-patient psychiatric wards and my Court work has covered a very wide range of legal issues.  The work continues to feel hugely rewarding to me and I am grateful for the trust placed in me by so many who have sought my services in distressing and difficult circumstances.

Carstairs Psychological Associates Ltd

Registered in England & Wales No. 5657675

Registered office

7 Mayfield Road,

Bromley,

Kent,

BR1 2HB

www.carstairspsych.co.uk

020 8325 1697